Healthcare Provider Details

I. General information

NPI: 1043630437
Provider Name (Legal Business Name): CDA DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SPARTANBURG RD
LYMAN SC
29365-1746
US

IV. Provider business mailing address

301 SPARTANBURG RD
LYMAN SC
29365-1746
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-1240
  • Fax: 864-439-1241
Mailing address:
  • Phone: 864-439-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6942
License Number StateSC

VIII. Authorized Official

Name: DR. CHRISTOPHER DEREK AYERS
Title or Position: PRESIDENT
Credential: DMD
Phone: 843-406-3678